the cretan mediterranean diet” - australian almonds › wp... · the cretan mediterranean diet”...
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The Cretan Mediterranean Diet”The optimal diet for cardiodiabesity?
Professor Catherine ItsiopoulosHead of School of Allied Health
Professor of Dietetics and Human NutritionLa Trobe University
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Professor Catherine Itsiopoulos
Head of School of Allied HealthProfessor of Dietetics and Human Nutrition,
La Trobe UniversityCatherine is a recognised leader in Dietetics and has international standing as a leader in Mediterranean diet research. She is an Accredited Practising Dietitian, the deputy chair of the Australian Dietetics Council, and is the founding head of the department of Dietetics and Human Nutrition at La Trobe University. Her current role is Head of School of Allied Health at La Trobe University. Catherine’s specific research area of interest is Mediterranean diet studies focussing both on migration impact on diet and lifestyle and chronic disease risk and dietary clinical intervention trials using the traditional Cretan Mediterranean diet (and elements of) as intervention models in the prevention and management of metabolic syndrome, Non-Alcoholic Fatty Liver Disease, type 2 diabetes, cardiovascular disease, and more recently mental health. Catherine has authored over 50 peer-reviewed publications with 720 citations, has co-edited a Nutrition textbook, and has published 2 Mediterranean Diet Cookbooks (The Mediterranean Diet 2013, The Mediterranean Diet Cookbook 2015).
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Globally Obesity has reached crisis proportions!
More than 2.1 billion – 30% of global population – are overweight or obese!
By 2030 it is estimated that 50% of our population will be overweight or obese.
Global economic impact of obesity is $2 trillion (2.8% GDP) via related diseases diabetes and CHD.
Obesity
biological
psychological
sociologicaleconomic
institutional
http://www.mckinsey.com/insights/mgi/in_the_news/the_obesity_crisis
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~2 MillionIn Australia
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We live in an Obesogenic Environment!
• Urbanisation
sedentary occupations
computerisation and mechanisation
improved transportation
• Nutrition transitions
exponential growth in fast food industry (highly processed, high fat, sugar, salt)
livestock revolution (intensively reared animals with a high n6/n3 fatty acid profile – 20:1 vs 2:1 – not enough omega 3!)
highly processed grains (poor in fibre, micronutrients, and phytochemicals)
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EVOLUTION???
http://lifedestiny.net/wp-content/uploads/2010/01/EvolutionOfMan.jpg
Somewhere, something has gone terribly wrong!
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Undesirable Food Trends in Australia 2015: What are Australian Eating? (NHS, 2011-2012)
Recent Australian Health Survey of 12,000 people shows that we are eating 30% less fruits and vegetables than 15 years ago.
25% of Adults eat NO vegetables on an average day and only 7% eating recommended 5 serves per day!
We eat 3kg of food and beverages each day and 35% of energy comes from high fat, high sugar foods such as cakes, biscuits, alcohol, soft drink and chips.
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Could a Mediterranean-style Diet be the answer?
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Historical Overview: Traditional Mediterranean diet studies
7 countries study
(1950s)
Lyon Heart study
(1990s)
Greek Paradox
Intervention (late 1990s)
PREDIMED (2013)
AUSMED Heart Trial
(2014-)
SMILE, MEDINA,
MEDIBRAIN,AUSMED ASTHMA
MEDLEY
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Ancient Mediterranean Diet: triad of “wheat, olive oil, and wine”
Archaeological finds such as stone mortars and presses used for olive oil extraction date back to 5000 BC!
http://www.explorecrete.com/nature/olive-oil-history.html
Considered as a ‘gift of the gods’ the olive tree was an important symbol for the ancient Greeks. It was connected to their diet and their religion and
considered a symbol of peace, wisdom and victory.
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Ancel Keys 1904-2004
“The Archetypal Cretan Mediterranean Diet”The 7 Countries Study
The Diet-Heart Hypothesis
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Heart Disease is Complex!
http://atvb.ahajournals.org/content/27/1/15/F1.large.jpg
OXI
DAT
ION
/ IN
FLAM
MAT
ION
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http://predimed.onmedic.net/Default.aspx?alias=predimed.onmedic.net/eng
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PREDIMED Final Outcomes
Figure 1. Incidence of Primary End-Point (a combination of acute myocardial infarction, stroke and all-cause death) following use of the Mediterranean Diet for the primary prevention of cardiovascular disease.EVOO = Extra Virgin Olive Oil
(Estruch et al, 2013)
Med diet, EVOO: hazard ratio, 0.70(95% CI, 0.53–0.91); P=0.009Med diet, nuts: hazard ratio, 0.70(95% CI, 0.53–0.94); P=0.02
Inci
denc
e of
car
diac
eve
nts
(%)
30% Reduction inCVD Mortality/
Morbidity Ef
fect
inde
pend
ent
of w
eigh
t los
s
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PREDIMED Cumulative diabetes free-survival: Med diets (a,b) vs control (c )
Salas-Salvadó J et al. Diab Care 2011;34:14-19
Copyright © 2014 American Diabetes Association, Inc.
55% RiskReduction DiabetesIncidence
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37% reduction in mortality in Q5 vs Q1 of polyphenol intake
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PREDIMED: Mortality and Polyphenol Intake (by type)
Tresserra-Rimbau et al. BMC Medicine, 2014
EVOOOleuropinHydroxytyrosolBitter/pungent
WineResveratrol
Legumes
Nuts
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Results suggest that a Mediterranean diet supplemented with 30g nuts/day (almonds, walnuts, hazelnuts) reduces the risk of depression in people withDiabetes.
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Healthy middle aged men (n=20), healthy young men (n=20) and young men with CVD risk factors (n=20) consumed 50g almonds for 4 weeks, compared to controls (n=15) who consumed habitual diet.
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Choudhury et al, Free Radical Research 2014
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Choudhury et al, Free Radical Research 2014
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Dietary Patterns and Protection for Type 2 Diabetes(Fardet and Boire, Nutrition Reviews 2014)
Figure: Radar plot of food groups and beverages and link with type 2 diabetes risk.protective ---------- neutral ------------ deleterious
A synthesis of all (304) pooled meta-analyses and systematic reviewed published 1950-2013
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Mediterranean Diet Protective for Deaths frommultiple conditions.
(Sofi et al, Adherence to Mediterranean diet and health status: meta-analysis. BMJ 2008:337:1344, Updated Sofi et al, AJCN 2010, Updated Sofi F et al Public
Health Nutrition, 2014)
Systematic review and meta-analysis of international studies between 1966-2010 involving over 4 Million people, demonstrated that a 2-point increase in adherence to a Mediterranean diet was associated with:
10% reductionoverall mortality
10% reduction in CVD deaths
6% reduction in Cancer deaths
13% reductionIn Alzheimer’s and
Parkinson’s
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BMC Medicine, 2015
Healthy DietFresh vegetablesSaladsFresh FruitGrilled Fish
Unhealthy DietRoast meat SausagesHamburgersSteakChipsCrisps and Soft drinks
N = 255, 46% Female, mean age 63 yrs, ACT
Greater retention of brain volume over 4 yrs
with healthy diet!
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Is a Mediterranean Diet Feasible in a non-Mediterranean Multi-Ethnic Society like Australia?
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12 week RCT of Greek-style Med diet “ad libitum” vs Usual Diet in T2DM
Clinically significant change in HbA1c (of the order found in many OH drug trials)
Change of - 0.3 HbA1c% = 10% reduction in CHD Mortality in T2 diabetes
Health benefits independent of weight loss!
First RCT using a reconstructed Cretan Mediterranean diet in a clinical trial in Diabetes in Australia.
Cooked meals and staples(olive oil, dried fruit, nuts,
sourdough bread) providedfor duration of study.
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After 6 weeks on a Mediterranean Diet there was an almost 40% drop in liver fat compared with only 7% drop on the low fat diet.
Insulin resistance improved on the Mediterranean Diet but no change on the low fat diet.
Ryan, Itsiopoulos, Thodis et al, 2014 Journal of Hepatology.
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AUSMED Heart Trial: Secondary Prevention of AMI with the Mediterranean Diet (2014 - )
AimsExamine the potential of a Mediterranean diet vs low fat diet in,reducing risk of secondary events at 12 months in patients surviving a cardiac eventmediating cardiometabolic markers at 6 months
DesignMulti-centre, parallel, RCT of 6 month intervention of Modern Med diet versus low fat diet. First secondary prevention trial using Med diet in non-Mediterranean multi ethnic population. Modelled on Lyon Heart study and using PREDIMED tools.
Intervention:
Tailored menus, cookbook and hamper of key staple foods (Med diet) vs control std diet for CVD risk reduction (NHF guidelines). Intensive dietetic counselling in both arms.
Recruitment to date: 49 - Med diet intervention arm (n=27) vs. low fat diet control arm (n=22)
Most common cultural backgrounds: Australian, European, and South Asian.
Feasibility: Med diet adherence score using 14-item PREDIMED tool shows intervention arm (n=16): baseline score 5.4 vs 6 month score 10.9
CIs: Itsiopoulos, Wilson, van Gaal, Tierney, Thomas, Kingsley, Brazionis, Vally, Salim, Segal. PhD students: Teagan Kucianski, Hannah Mayr
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Our Mediterranean trials experience: Challenges and Solutions!
Challenges SolutionsCultural diversity/ interest in Med diet Adjust current foods embedding key Med diet ingredients
Fear of eating too much fat –4 tbs EVOO/ day
Focus on heart health benefits of EVOO, polyphenols, taste
Dislike of some food staples (yoghurt) Try plain Greek-style with fresh fruit, walnuts, honey
Concern over eating “carbs” e.g. bread/ pasta Approach is moderate carbs, focus on sourdough/grain, and high plant:animal food ratio
Poor cooking skills/ no time to cook Focus on ‘no cooking req’ options, cook in bulk and freeze
Ingredient challenges (garlic, EVOO, leafy greens, legumes) Add spinach and lentils to lasagne.Bake veggies with garlic and EVOO.Simple lunches – leafy salad, tinned salmon/tuna, 4 bean mix, EVOO.
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AUSMED Heart Trial: Adherence to Mediterranean Diet at 3 months
Mayr et al, ICD Conference 2016
AlmondsWalnuts(Hazelnuts)
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Why is the Mediterranean Diet beneficial in cardiodiabesity?
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Ref: Simopoulos and Sidosis. What is so special about the Greek diet? World Rev NutrDiet 2000
•Vit C•Vit E
•Carotenoids•Phytoestrogens
•Phenolics•Allylthiosulfinates
•Flavonoids•Selenium
•N3 fatty acids: ALA and EPA DHA
Anti-inflammatory/ Palatable/Sustainable/ Ecological
4:1 Plant to Animal Food Ratio
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A predominantly plant-based diet with fish and seafood!
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Balanced Plate – Mediterranean Style
4:1 ratio of Plant: Animal Foods
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The Mediterranean Diet is High in Omega-3 fats from a range of sources.
Offal – κοκορετσι!
Wild edible leafy greens Nuts
Greek village eggs“free range”
fotobank.ru/image/FC01-8880.html
Free range goat- milk and cheese
Snails (Crete)
www.dreamthymefarm.com/goat_meat.html
Pumpkin seeds‘πασατεµπο’
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Protective Metabolic Pathways
Jordi Salas-Salvadó et al. J. Nutr. 2016;146:920S-927S
©2016 by American Society for Nutrition
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Translating the Mediterranean Diet Principles: The Toolkit
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Assessing Adherence:PREDIMED 14-Item Diet Quality Guide
14-item food diet quality guide: PREDIMED Study (Martinez-Gonzalez et al, 2013).
Foods Positively Associated with Mediterranean Diet
•Olive oil as main fat•> 4 tbsp olive oil/day•> 2 serves vegetables (2x200g cooked, 100g raw)/day•> 3 serves of fruit/day•> 7 glasses wine/week (If a consumer of alcohol) •> 3 serves (3x150g) legumes /week•> 3 serves fish (100-150g) or shellfish (200g)/week•> 3 serves (3x30g) nuts/week•Chicken, turkey, wild meats as main meats•> 2/week dishes cooked in tomato, onion, garlic, olive oil (sofrito or salsa)
Foods Negatively Associated with the Mediterranean Diet
•< 1 serve red meat/meat products (100-150g)/day•<1 serve butter, margarine or cream/day•< 1 sweet/carbonated beverage/day•< 3/week commercial sweets, cakes, biscuits.
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Translating the traditional Mediterranean Diet: 10 Commandments
Extra Virgin Olive oil as the main added fat!
Vegetables /salads with every main meal
Legumes twice per week
Meat/Chicken less often, small portions
Wholegrainsourdough
breads
Wine in moderation,always with
meals.Sweets on special occasions
Use herbs and spices to flavour foods
1
2
3
4
5
Fish/seafood twice a week
6
7Fresh fruiteveryday
Fermenteddairy every day
“yoghurt”8
9Nuts everyday
10
Itsiopoulos, C
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New Nutrition Australia pyramid has a strong Mediterranean Diet focus!
Predominance of fruits and vegetables
supporting and 4:1 plant to animal food
ratioHerbs and spicesincluded
Olive oil includedin pyramid
Moderate in carbohydrates
Legumes in eat most section
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Traditional Mediterranean plate4:1 Plant to Animal Food ratio
Typical Australian-born Anglo-Celtic Plate 2:1 Plant to Animal Food ratio
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Putting the Mediterranean Diet into Practice!
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The solution is not just about changing our diets!
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Try to emulate the Long Living “Blue Zones” Populations?
• Populations around the world living beyond 100 yrs:
– Okinawa (Japan)– Sardinia (Italy)– Nicoya (Costa Rica)– Lima Loma (California)– Ikaria (Greece)
• Key lifestyle features of Ikarians (Itsiopoulos et al, 2016):
– Very low levels of stress, happiness, and positivity– no smoking (in women)– active social life and being productive– Family coherence, eating together– physically active, walking everywhere, keeping home garden– a high plant-food diet focussed on fresh local foods and free range
produce. www.bluezones.com
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• Professor Kerin O’Dea• Prof Peter Brooks• Dr Laima Brazionis• Dr Andrew Wilson• Dr Marno Ryan • A/Prof Antigone Kouris• Dr Audrey Tierney• A/Prof Bill van Gaal• Dr Hassan Vally, • Dr Colleen Thomas • Dr Agus Salim• A/Prof Michael Kingsley• Natalie Simmance• Tanya Gilliver• Dr Jessica Radcliffe• A/Prof Catherine Itsiopoulos
PhD Students• Tania Thodis
• Spero Tsindos
• Rachelle Opie
• Teagan Kucianski
• Elena Papamiltiadous
• Serpil Kucuktepe
• Hannah Mayr
• Oana Tatucu
Thank you to the Researchers and industries providing foods for our studies.